I. Symptoms

  1. Constant pain or fluctuating pain
  2. Posture changes affect Abdominal Pain
  3. Abdominal Pain not related to bowel function
  4. Abdominal Pain not related to meals
  5. Discrete, small, coin size pain Trigger Point
    1. Lateral margins of rectus abdominis muscles
    2. Muscle or fascia attachments tender
  6. No symptoms suggestive of intra-abdominal process
    1. No Nausea or Vomiting
    2. No Diarrhea or Constipation
    3. No weight loss
    4. No fever
    5. No rectal bleeding or Anemia

II. Signs

  1. Carnett's Sign positive
  2. No signs suggestive of Acute Abdomen

III. Causes

IV. Labs

  1. Normal inflammatory labs
    1. White Blood Cell count (WBC) normal
    2. Erythrocyte Sedimentation Rate (ESR) normal
    3. C-Reactive Protein (CRP) normal

V. Approach: Step 1 Evaluate for Visceral Pain

  1. See Acute Abdominal Pain
  2. Evaluate Carnett's Sign
    1. Positive (pain not improved with tensing Abdomen)
      1. Go to Step 2 below (Abdominal Wall Pain)
    2. Negative (Pain improves with tensing abdominal wall)
      1. See Acute Abdominal Pain

VI. Approach: Step 2 Evaluate for Hernia

  1. If no scar or obvious Hernia, go to step 3
  2. Hernia palpable on exam
    1. Surgery Consultation
  3. Non-palpable Hernia suspected at scar
    1. No relief with Trigger Point Injection
    2. Consider imaging studies
    3. Consider surgery Consultation

VII. Approach: Step 3 Musculoskeletal Cause

  1. Spinal movement increases pain
    1. Suspect intercostal nerve root irritation
    2. Consider local Trigger Point Injection
  2. Anatomically localized pain
    1. Evaluate for Hernia
    2. Evaluate for cutaneous nerve entrapment
    3. Evaluate for slipping rib syndrome
  3. Rectus abdominis pain
    1. Evaluate for Rectus sheath hematoma
    2. Evaluate for Myofascial pain

VIII. Approach: Additional Measures

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